38yr male UTI with BPH

Hello everyone! I am an intern in medicine department. One of the important terms of getting internship completion is to complete my daily log with what I learn during course of my duties

  Case presentation:
    A 38 year old male came with compliants of dysuria with reduced urine output since four days and pain in hip region since 4 days.

HOPI:
        Pt. was apparently asymptomatic four days back then developed burning micturition which was not subsiding with medications. 
History of dysuria,reduced urine output
No history of fever,chills,rigor
Pain in hip region during standing and sitting.
No history of trauma; pt. is able to do his daily activities

Past history:
  Known case of DM since 5years
  Not k/c/o HTN,TB,asthma,epilepsy,chronic heart and kidney diseases
 
Personal history:He is a smoker since 15 years.smokes 2-4 cigarettes per day.
  diet is mixed
  Appetite is regular
  Bowel movements are regular 

No significant family history 

GENERAL EXAMINATION:
Patient is c/c/c and oriented.
Moderately built and moderately nourished
Temperature:afebrile
Pallor-absent
Icterus-absent
No cyanosis,clubbing and lymphadenopathy
Bp:140/90 mm Hg
PR:75 bpm
RR:16/min
SPO2:99%
CVS:S1 and S2 heard,no murmurs
RS:BAE present NVBS.position of trachea central
P/A: Suprapubic tenderness is present
CNS examination: Intact
         
           There is a difficulty in  passing Foley's catheter..took surgeon opinion and passed 10 number feeding tube with help of guide wire and more than 1000ml urine is collected in urobag after passing tube.

Investigations:
ECG:
USG abdomen:Grade 2 prostamegaly

Hemogram:
CUE:
Culture and sensitivity-urine:
RFT and LFT:
HBA1C:

Diagnosis:
        UTI with BPH and k/c/o DM

Treatment:
    1. Syp.Citralka 15ml in 1 glass of water TID
    2. Inj.Pan 40mg iv od
    3. Inj. Optineuron 1amp in 100ml NS of
    4. Tab.MVT od
    5. Tab.Tamsulosin-D 0.4/0.5mg 15 days
    6. Tab. Glimi-M1 od
    7. Tab. Taxim 200 mg bd for 1 week





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